Regions Hospital Best Fed Beginnings

Dr Teresa F Kovarik

Baby Friendly Hospital Initiative (BFHI)

• International hospital designation in maternity care, e.g. Magnet status

• Developed by UNICEF & WHO in 1991 • Gold standard for evidence-based BF care • Ten Steps proven to improve BF rates • Maternity care that emphasizes best practice

in infant feeding • Significant gap between evidence-based

recommendations & actual practice

Best Fed Beginnings

• CDC & NICHQ recruited 90 hospitals nationwide; end goal BFHI designation

• 22 mo learning collaborative to lead the way as innovators in QI & maternity care

• Create a template for best practice in infant feeding for other hospitals to follow

• Cultural change in patterns of care in the hospital

Step 6

• Give NB infants no food or drink other than breast milk, unless medically indicated

• Mandates that hospitals pay fair market value for formula & feeding supplies

• Emphasizes helping parents make an informed decision re milk choice & supplementation

Formula Supplementation

• Hospital formula supplements associated w/ – delayed onset of lactogenesis

– Suboptimal BF practices

– Perceived problems w/ BF during hospital stay

– Undermining mom’s confidence that she can meet her child’s nutritional needs

– Shorter duration of exclusive BF

• Hospital formula supplementation can wipe out all the other + benefits of the other Steps when looking @ odds of mothers achieving their exclusive BF intention

Fair Market Value for Formula

• Director of Nursing at Regions met with materials management who then negotiated with formula companies

• Regions paying for Similac since 1-2012; Enfamil since 7-2012; hospital-wide

• Used middle tier payment structure initially

• Working towards more appropriate fair market value

Gift Bags

• Regions banned discharge gift bags with formula in 2009

• New gift bags collaborative effort between Dietary, Parking, Best Care Best Experience group

• Parking voucher, gift card to cafeteria, baby T-shirt, all in reusable bag

Informed Milk Choice

• Education re risks of formula supplementation begins prenatally – Benefits of breast milk

– Best practice for BF support

– Setting expectations for new parents

• Postpartum re-education if BF mother requests formula – Scripting for staff

– Parental education re how to console infant

– Predict feeding patterns for each day of life

Supplementation Policy

• Formula kept in locked cabinet in NBN unit

• Nurse documents in Epic

– Education given to parent re supplementation risks

– Reason for supplementation in dropdown list

• Supplementation w/ SNS, gavage, cup or finger feeding with dropper; teach mom method

• Provider order required for supplementation unless maternal request

Medical Indications for Supplementation in Term Infants

from ABM clinical protocol #3

• Maternal illness separating infant & mother

• Infant w/ inborn error of metabolism

• Infant who is unable to feed @ breast (congenital malformation, illness)

• Maternal medications contraindicating BF (check Hale or LactNet)

Possible Medical Indications for Supplementation in Term Infants

from ABM clinical protocol #3

• Asx hypoglycemia documented by serum BG unresponsive to frequent BF (Sx infants get IV Glc)

• Evidence of significant dehydration (>10% wt loss, high Na, poor feeding and outputs, lethargy) not improved after skilled & proper BF management

• Wt loss 8-10% w/ delayed lactogenesis (day 5 on)

• Delayed stooling or meconium still on day 5

• Poor milk transfer seen by outputs or wt pre/post

nursing

Possible Medical Indications for Supplementation in Term Infants

from ABM clinical protocol #3

• Jaundice associated with starvation seen by poor wt gain & outputs despite appropriate intervention

• Bili levels > 20-25 mg/dL in otherwise thriving infant

• Intolerable pain in mother during feedings unrelieved by skilled interventions

Documentation of EBF

• Every shift under Infant Feeding in Epic each nurse documents – If infant exclusive BF

– If supplemented, then reason documented

• Real-time monitoring in daily report also of – S2S, if no reason why, timing

– Rooming in

– Education of parents by staff

– Assistance & support with BF

– Feeding on cue

Conclusion

• BF is an important public health issue.

• Most US hospitals fall FAR short of implementing evidence-based best practices so current US BF rates well below Healthy People 2010 goals.

• Ten Steps increase EBF by 30-40% & significantly increase BF duration rates as well.

We have the Steps to provide substantial lasting benefits for maternal & child

health.

It starts with us.